Table Of Contents
Terms
| Macromastia | >500gm/breast |
| Gigantomastia | >1000gm/breast |
Breast Surgery Types
| Breast Augmentation | surgery to increase breast size | involves placing breast implants under breast tissue or chest muscles |
| Breast Implants | silicone or saline filled prosthesis | |
| Lumpectomy | local surgery for breast ca | only taking out the problem |
| Mastopexy | putting breast tissue back where it’s supposed to be w/ a small implant |
Breast Augmentation
Breast Augmentation Types
| Procedure | Advantage | Disadvantage | |
| areolar | small incision just around the areolar complex | small implants only heals really well – scar barely seen | |
| axillary | tunnel a pocket in the breast | scar pretty well healed | |
| inframammary | incision directly in the fold under the breast | heals well but you will see a scar | |
| transumbilical | incision made in the navel area | roll it up & then fill with saline & watch how it inflates |
Breast Augmentation Post-op
- pain meds
- muscle relaxants
- abx
- cathartics, antiemetics
- remove dressing on day 2 leaving steri-stips intact, showering permitted, arms & elbows at side x1wk
- no heavy lifting, exercise, swimming, or tanning 4-6wks
- breast massage & downward exercise 1wk post op
Breast Implants
- Recommended for pts:
- Replaced:
- q10 years
Breast Implant Types
| Silicone | Saline | |
| Viscosity | more viscous | viscous |
| Look and texture | look and feel more natural | feel harder |
| Show thru skin | less likely | folds may be visible |
| FDA approved Breast Augmentation | at least 22 yo | at least 18 yo |
| FDA approved Breast Reconstruction | any age | any age |
Placement of implants
| Procedure | Advantages | Disadvantages | |
| dual-plane | placing the implants partly behind the breast and partly behind the muscle | – Fewer complications – natural result particular for thin patients with very small breasts | – Rippling possible on the bottom of implant • More pain and longer recovery • Bottoming out may occur |
| subfascial | it places the breast implant in front of the muscle, under the connective tissue that covers the pectoral muscle | – less injury to the breast tissue during surgery – placement more comfortable after healing – much lower risk of breast implant failure – reduced risk of capsular contraction and maintaining its proper positioning – patient can return to an active lifestyle sooner | |
| subglandular | TUBA between the normal breast tissue & muscle of the chest | more encapsulation | |
| submuscular | axillary incision bc you are sep the serratus & pec minor from the side | Most natural-appearing breast implant avoid breadloafing | Not good for an athletic pt – they will look deformed |
Mastectomy Types
| Definition | |
| Simple | only breast tissue |
| Modified radical | breast tissue + some invasion into axilla + sentinel node |
| Radical | breast tissue + pectoralis muscle + axillary LNs |
| Partial | removal of the cancerous part of the breast tissue and some normal tissue around it |
| Nipple-sparing | all of the breast tissue is removed, but the nipple is left alone |
Post Mastectomy Breast Reconstruction
- Purpose:
- Reconstruction begin in pt w/ breast ca:
- Factors:
- Tissue Exapander Use:
- Post-reconstruction:
| Considered | Avoided | ||
| reconstructive ladder | Secondary intention –> direct tissue closure –> skin graft –> local tissue transfers –> distant tissue transfers –> free tissue transfers |
Post Mastectomy Breast Reconstruction – Implant Types
| Definition | Advantages | Disadvantages | |
| Direct to Implant reconstruction | bypass a preliminary surgery where temporary breast tissue expander implants are inflated over time to stretch the overlying skin and muscle | – shorter, less complex surgery – uses the mastectomy incision for procedure (doesn’t create new scars) | – take longer (multiple steps, multiple office visits to receive tissue expander injections) – look and feel less like natural breast – subject to future problems such as rupture, deflation, capsular contracture – implant won’t last a lifetime |
| Two-stage reconstruction | 1. Tissue Expander Surgery 2. Implant Reconstruction | – simple and predictable – No donor site morbidity – Shorter surgery time – Shorter recovery | – Req. a minimum of two operations – Lengthy process (numerous and frequent visits for expansion) – Req. good quality skin – Increased potential for capsular contracture |
Alternative to Implants
Flap Procedures
- Problems:
- Blood supply MC:
- Axial
Flap Procedures Types
| Procedure | Advantages | Problem | |
| deep inferior epigastric perforator flap | deep inferior epigastric perforators (DIEP), the skin and fat connected to them, are removed from the lower abdomen and transferred to the chest | ||
| free TRAM flap | same procedure as the pedicle TRAM flap but without the pedicle you must take it out & perform a microsurgical vascular reattachment when you get it to the site of reception | no connection to the blood supply no tunnelling under | |
| gluteal free flap | take it from their butt or inner thigh | without connection to vascular supply | |
| latissimus dorsi flap | skin, muscle, fat tunneled from back under the skin to the front of the chest | keeps the vascular supply most successful in women who smoke | |
| pedicle TRAM flap | skin fat & muscle from abdomen is tunneled under the skin to the chest | site of donor tissue remains attached w/ blood supply | higher incidence of hernias |
| transverse upper gracilis flap | take it from their butt or inner thigh | without connection to vascular supply | |
| transverse rectus abdominis muscle flap |
Reduction Mammoplasty
| Recommend for pts w/ | |
| – inframammary intertrigo – degree of breast proptosis – degree of enlargement – skin lesion on breast envelope – sensation of nipple-areolar complex – nipple dc – shoulder notching – kyphosis |
Reduction Mammoplasty Types
| Procedure | Advantages | Disadvantages | |
| Inferior pedicle tech (Anchor type or inverted T) | leaving a pedicle of tissue with the nipple in the superior portion of the pedicle, creating a wedge-shaped pedicle down to the chest wall | Most Common procedure | |
| Free nipple graft tech | nipple and areola are completely removed and then replaced as a skin graft at the end of a breast reduction | It is performed very rarely in cases in which the breasts are extremely large | |
| Liposuction | removing excess fat from under the skin by suction | ||
| Horizontal Scar tech | horizontal incision along the inframammary fold (IMF) and a NAC pedicle | ||
| Vertical scar tech | shorter scar that does not extend medially and laterally along the inframammary fold | – Reduced scarring, improved shape, long-term shape retention, and good nipple sensation – best for removing small areas of the skin envelope and small volumes of internal tissues |
Liposuction
- Purpose:
- Places done:
Liposuction Types
| Procedure | Advantages | Disadvantages | |
| laser-assisted | uses laser energy to liquefy fat cells | melting the fat to make the suction of the fat out of the body easier | |
| tumescent | several quarts of a solution are pumped below the skin in the area from which fat is to be suctioned | ||
| US-assisted | uses ultrasonic vibrations to turn fat cells into liquid | melting the fat to make the suction of the fat out of the body easier |
Post-op Liposuction
Abdominoplasty
- Procedure:
- Purpose:
- NO LIPO W/ ABDOMINOPLASTY
- traditional abdominoplasty
- umbilicus get reconstructed after abdominoplasty
- complications:
Facial Surgery
| Indications | |
| Face/neck lift | excess skin and fat of face and neck, vertical bands of neck |
| Blepharoplasty | excess skin and/or fat of eyelids Functional indication: impairing vision |
| Browlift | excess forehead and “heavy” brows, constant “angry” look – usually performed w/ blepharoplasty. |
Rhytidectomy
- Def:
- Purpose:
- 3 places that succumb to gravity:
- aging face
- face wrinkle due to:
- MC procedure for rhytidectomy:
- Pts are happy after:
Rhytidectomy Types
| Main focuses | Advantages | Disadvantages | |
| SMAS | Mobilization Repositioning Fixating | deeper dangerous due to all of the nerves | |
| Deep plane facelift | better nasolabial fold appearance in rhytidectomy | greater auricular nerve facial nerve | |
| Thread lifts | nasolabial fold | younger people a small opening only placed under the skin minimally invasive | |
| Minimal access cranial suspension lift | minimally invasive procedure that will help to lift the nasolabial fold |
Skin Graft
| Characteristics | Ideal site | Full Thickness utilized | Inappropriate | Lead to Failure |
| BUGS Blood supply Underlying tissue Graft thickness Structures present that need covering | Over muscle or fascia or other vascularized, stable tissue | over precarious takes eyelides, nose, hand, joints | Over hardware Over a fracture Over tendons devoid of paratenon Over repaired tendons Over bone without periosteum | Poorly vascularized bed Colonized/infected wound bed Shearing stress before graft adherent Excessive swelling |
Three phases of a graft take
- 1. Plasma imbibition ( is a special type of diffusion when water is absorbed by solids-colloids causing an enormous increase in volume. Examples include the absorption of water by seeds and dry wood.) (24-48 hours)
- 2. Inosculation – alignment of recipient/donor capillaries
- 3. Revascularization (5-7 days)
